Is it worth appealing: what the numbers say

Often it is worth trying, but no one can promise you a result. The published numbers say that most denials are never appealed, that some appeals do change the outcome, and that results differ a lot by program. They cannot tell you about your case. Use them to understand the picture, then decide from your own facts and your deadline.

What this means

What the numbers say

Each figure below has its own year, scope and source. They are not interchangeable.

• Few people appeal. In 2024, consumers appealed at least 262,982 of the roughly 85 million in-network claims that insurers selling HealthCare.gov Marketplace plans denied, which is fewer than 1%, according to KFF (a health policy research organization, formerly the Kaiser Family Foundation). That covers HealthCare.gov states only and says nothing about employer plans. In KFF’s 2023 survey of insured adults, 15% of those with a denied claim filed a formal appeal, and 69% did not know whether they had appeal rights.
• Marketplace internal appeals, 2024. KFF reports that insurers upheld 66% of appeals in 2024, meaning the plan stood by its denial.
• Medicare Advantage prior authorization, 2024. In KFF’s analysis of 2024 data, published 28 January 2026, Medicare Advantage insurers fully or partially denied 7.7% of about 52.8 million prior authorization determinations. Of those denials, 11.5% were appealed, and 80.7% of appeals were partially or fully overturned.
• Medicaid managed care, 2019. A 2023 report by the Office of Inspector General of the United States Department of Health and Human Services, covering 2019 data from 115 plans run by the 7 largest parent companies in 37 states, found enrollees appealed 11% of denials of prior authorization requests and plans reversed 36% of the appealed denials. Only 2% of upheld denials went on to a state fair hearing.
• External review in one state. California’s Department of Managed Health Care cites its 2025 annual report as saying about 78% of members who requested an Independent Medical Review received the service. Of 3,290 medical-necessity reviews in 2025, 57.39% were overturned by the reviewer, 23.01% were reversed by the plan itself and 19.60% were upheld. This covers California plans that department regulates, not the nation.

Why you cannot line them up

• Different programs, different rules. Medicare Advantage plans must follow Original Medicare’s coverage rules; Marketplace plans follow the Affordable Care Act and their plan terms. The two KFF figures describe different sets of insurers and different kinds of decisions.
• Different measures. One figure is “upheld”, another is “partially or fully overturned”, another counts a plan reversing itself. They are not opposite sides of the same coin.
• Same data year, different publication. Both KFF figures come from 2024 data, published two months apart (28 January 2026 and 24 March 2026), and neither covers employer plans.
• KFF’s own counts do not match its percentage. The two counts KFF gives for 2024 divide to about 63%, not 66%, and KFF says the appeal count is a minimum because small values are suppressed. We quote KFF’s 66% as KFF’s figure and do not turn it into an overturn rate.
• No national external review figure. We found no official nationwide overturn rate for external review.

What to do

1. Name the reason and its family. A paperwork reason may need a call and a corrected claim, not an appeal. See the three families of denial reason.
2. Check your plan documents. If the plan excludes the service outright, an appeal is harder, though a medical judgment or a plan error can still be at issue.
3. Ask your doctor whether they believe the care is needed and whether they will support you with a letter or a peer-to-peer call.
4. Ask for the claim file. It is free, and it shows how thin or strong the plan’s case is. Use the claim file request.
5. Count the cost honestly. An internal appeal costs time and attention, not a filing fee. A state external review process may charge up to $25 where state law allowed that fee in 2015. Weigh that against the amount, the care, and your energy.
6. Decide with your deadline in view. Use the deadline calculator. If you are unsure, do not let the date pass while you decide.
7. Get help. A free counselor or advocate can give a second opinion; see where to get free help.

The rule

A plan cannot charge a fee to file a claim or an appeal. Under the federal external review process you may not be charged anything, including filing fees. Source: Code of Federal Regulations (CFR) Title 29, section 2560.503-1(b)(3) and 29 CFR 2590.715-2719(d)(2)(iii)(A)(4). A state process may keep a small fee in limited cases; check the date on your notice, which controls.

Watch for

• Averages hide cases. A high or low figure for a whole program says little about one claim.
• Figures on other sites may not trace back. Claims like “most appeals win” appear on many sites. We could not confirm several of them against a primary source. Look for the year, scope and source.
• Older figures. A 2018 federal report found Medicare Advantage plans overturned 75% of their own denials on appeal in 2014 to 2016, while only 1% of denials were appealed. That figure covers payment as well as prior authorization denials and is old.
• A win may be partial. Outcomes can be a full reversal, a partial one, or a different service approved.
• Not worth the effort sometimes. Small amounts, clear exclusions, or care you no longer need may not justify an appeal. That is your decision to make, and you may wish to talk with your provider or a legal aid service first.

What next

• Try the cheaper step first where it fits: fix it without an appeal.
• Learn the independent step: how external review works.
• See what remains if all appeals fail: after a final denial.
• Go to the topic page, know your deadlines.